Health inspection·November 19, 2020

F 0558 a. ADL self-performance deficit. Interventions included: Encourage resident to use bell to call for assistance. Level of Harm - Minimal harm or potential for actual harm b. Altered Cardiovascular status. Interventions included: Assess for chest pain as needed. Enforce the need to call for assistance if pain starts. Residents Affected - Few c. Communication problem related to slurring due to stroke. Interventions included: Ensure/provide a safe environment: Call light in reach. d. At risk for falls related to gait/balance problems. Interventions included: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Frequent checks per physician order. e. The resident has actual/potential impairment to skin integrity related to fragile skin, blisters to back with itching, pressure areas to heels. Interventions included: Encourage good hydration in order to promote healthier skin. During an interview with Certified Nursing Assistant (CNA) N on 11/19/2020 at 2:45 PM, she stated Resident #135's call light was not within reach. She did not think he could use his call light. She did not state that he was on 15-minute checks. She left the room and did not address the resident's need for a way to alert staff or for checks/rounding. 2. Resident #44 interviewed on 11/16/20 at 9:12 AM. The head of her bed was elevated 45 degrees. Her neck and head were bent over to her right side. Her right hand was in a hand splint. She appeared sleepy and groggy. She spoke with a feeble voice and appeared weak. She was only able to slightly raise her head. She made eye contact, smiled and whispered her answers. She stated she did not feel well. There was no hand bell on her tray table and the call light did not work. On 11/16/2020 at 4:15 PM, the call lights for Resident #44 and her roommate (Resident #45) were clipped on the cords against the wall behind the privacy curtain. Neither resident could reach their call light. (Photographic evidence obtained) The call light system had been repaired earlier in the day. On 11/17/2020 at 9:15 AM, Resident #44 was lying in bed with her tray table over her bed. Her right hand was in a hand splint. She had a spoon in her left hand and was eating a pudding supplement out of a plastic cup. She stated she wanted some water but could not reach it. The water cup was on her right hand side of the table. Her call light was not within reach. It was tied around the bed rail. When asked if she used her call light she stated, Yes, I think I need that. The resident was handed her call light and she put it on. On 11/18/20 at 2:45 PM, Resident #44 was observed lying in bed with a blanket covering her up to her chest. She was not in distress. Her call light was tied up against the wall and not within reach. Resident #44 was interviewed on 11/18/20 at 2:45 PM. She was lying in bed with her covers on. The call light was clipped against the wall behind the privacy curtain. Resident #44 stated her stomach was upset. She had not told the nurse yet. She wanted to have help with putting the straw in her unopened milk carton. This surveyor pushed the call light. CNA K responded to the call light. When shown the call light she stated, Oh yeah, she needs this. and took the call light and clipped it to the bedspread next to the resident's left hand. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105632 If continuation sheet Page 2 of 29 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Harts Harbor 11565 Harts Rd Jacksonville, FL 32218 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Licensed Practical Nurse (LPN) A was interviewed on 11/18/20 at 2:58 PM. She was asked to see this resident about her upset stomach. She was informed that the resident's call light was clipped against the wall and not within reach. She was asked if the resident could use her call light and she stated, Yes, she can use it. She confirmed the CNAs needed to clip the call light near her left hand so she could use it. Resident #44 was observed on 11/19/20 at 9:41 AM. Her water cup was on her right hand side of the tray table not within her reach. The date on the water cup was 11/18/2020. (Photographic evidence obtained) Resident #44 was observed on 11/19/20 at 5:34 PM. Neither the call light nor the water cup was within her reach. Resident #44 was admitted on [DATE]. Her DOB was [DATE]. Her diagnoses included arthropathy, muscle weakness, difficulty walking, anorexia , type II diabetes with hyperglycemia, schizo-affective disorder, heart disease, gastroparesis, hyperlipidemia, anxiety, chronic kidney disease - stage 1, anemia, hypertension, major depressive disorder, gastroesophageal reflux disorder, dementia without behavioral disturbance, protein-calorie malnutrition, glaucoma, ulcerative colitis with unspecified psychosis not due to substance or known physiological condition, dysthymic disorder, unspecified abdominal pain, unspecified pain and dry eye syndrome. A review of the MDS assessment dated [DATE], revealed the resident required limited assistance with most ADLs. She required extensive assistance to walk, for personal hygiene and dressing. She had impairment on one side of her upper extremities (right). Her BIMS score was 01, indicating severe cognitive impairment. A review of the care plan dated 09/13/2020, revealed the resident had focus areas including: a. ADL self-performance deficit. Interventions included: Encourage resident to use bell to call for assistance. b. The resident is at risk for falls related to history of falls, confusion, gait/balance problems, incontinence, psychoactive drug us and vision/hearing problems. Interventions included: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Encourage to call for assistance. 3. Resident #45 was observed and interviewed on 11/16/20 at 9:00 AM. She was lying in her bed with her tray table across the bed. The head of her bed was elevated 45 degrees. She was covered with blankets. She was asked whether she knew how to use the call light system and she stated she did. The call light system on this unit was temporarily out of order per administration. Resident #45 did not have a tap/hand bell in sight, and she stated she did not have one when asked. On 11/16/2020 at 4:15 PM, the call lights for Resident #45 and her roommate #44 were clipped on the cords against the wall behind the privacy curtain. Neither resident could reach their call light. (Photographic evidence obtained) The call light system had been repaired earlier in the day. During an interview with the Director of Nursing (DON) on 11/16/2020 at 9:20 AM, she was asked whether the resident was able to use (and did use) her call light. She laughed and stated, Oh yes, she knows how. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105632 If continuation sheet Page 3 of 29 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Harts Harbor 11565 Harts Rd Jacksonville, FL 32218 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the MDS assessment dated [DATE], revealed the resident was assessed for cognitive function. Her BIMS score was a 06 out of a possible 15 points, indicating severe cognitive impairment. The resident required extensive assistance of one staff member with most ADLs. She could eat independently with set up assistance. She had no impairment of her upper or lower extremities. A review of the facility's policy and procedure entitled Call Bell System-Inoperable, N-1141 (effective 11/30/2014 and revised on 08/22/2017) revealed: Resident must have, at all times, a system to notify when assistance is needed. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105632 If continuation sheet Page 4 of 29 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Harts Harbor 11565 Harts Rd Jacksonville, FL 32218 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation and interview, the facility failed to ensure a home-like environment for two (Residents #1 and #66) of 31 sampled residents whose rooms lacked individual decorations. Residents Affected - Few The findings include: Observations made on 11/17/20 at 12:15 p.m., included Resident #1's room. There were no decorations on the wall. During an interview on 11/17/20 at 12:19 p.m., Resident #1 stated, I miss my pictures of my granddaughters. They are all I have. I have three pictures and I like to keep them hanging on my wall, but no one will hang them for me. I told the staff and the maintenance guy back in August, but no one came to do it. During an interview on 11/17/20 at 12:32 p.m., Resident #66 (Resident #1's roommate) stated, My daughter bought me a clock and it is just sitting there in the box. I would like to have a clock. That is how I stay with reality. I told my nurse about it, and she said she would check on it and let me know. This was six weeks ago, and they have been here a couple of times. You can never get them to put it up. During an interview with Employee B (maintenance staff) on 11/19/20 at 1:50 p.m., Employee B revealed that he was aware of Residents #1 and #66's requests, but he got very busy getting other things done. He stated, We're shorthanded and I have to prioritize. I didn't have the drill for the wall. They have a concrete wall. I had to buy it myself. I will get it done today. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105632 If continuation sheet Page 5 of 29 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Harts Harbor 11565 Harts Rd Jacksonville, FL 32218 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and facility policy review, the facility failed to ensure it implemented its abuse and neglect policy and failed to investigate an injury of unknown origin for one (Resident #125) of three residents reviewed for the care area of abuse. Resident #125 had a bruise of unknown origin on his arm. Residents Affected - Few The findings include: A review of Resident #125's medical record revealed he was admitted to the facility on [DATE] with diagnoses including dementia, traumatic brain injury, schizo-affective disorder and difficulty walking. Resident #125 scored a 2 out of a possible 15 points on his Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. A review of Resident #125's Progress Notes, revealed a note from Licensed Practical Nurse (LPN) A, dated 10/13/20, concerning an injury of unknown origin. The note stated, Today I noticed he had a bruise to the back of his upper arm. I asked him how did that happen, and he stated he did not know how that happened. He stated that he was not in any pain. I notified NP (nurse practitioner) and she is aware of the situation and no new orders. During an interview with the Director of Nursing (DON) on 11/19/20 at 1:50 p.m., she stated she had no knowledge of Resident #15's injury. The DON stated she wasn't sure whether Resident #125 had been abused because LPN A failed to communicate this injury to her. On 11/19/20 at 3:00 p.m., the DON revealed that LPN A did not provide her much information about Resident #15's injury and she was suspended. She explained that injuries of unknown origin would be investigated to determine if there was possible abuse. The expectation for nursing staff was to communicate any injury of unknown origin to her, the DON. She further stated, They should know to report it to me. I am available, and they can contact me over the phone. It was confirmed that there was no investigation into how the bruising may have occurred, including statements from witnesses about potential causes. A review of the facility policy titled Abuse, Neglect and Exploitation, revealed that the staff was required to report observed or suspected abuse to proper authorities. The policy was dated 11/28/17. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105632 If continuation sheet Page 6 of 29 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Harts Harbor 11565 Harts Rd Jacksonville, FL 32218 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to conduct an accurate comprehensive assessment for one (Resident #7) of one resident reviewed for smoking. The findings include: Resident #7 was admitted to the facility on [DATE] with a primary medical diagnosis of seizures. Her secondary medical diagnoses included bipolar disorder and schizo-affective disorder. Her cognition was intact and she was able to make her own medical decisions. The resident required extensive assistance with most activities of daily living. On 11/17/20 at 11:11 AM, Resident #7 was observed exiting the main dining room through a door leading to the courtyard. The resident removed a cigarette from a pack being kept on her person. She then retrieved a lighter from her coat pocket, lit the cigarette, and proceeded to smoke. The facility's assistant administrator was notified. She assisted the resident back into the facility and explained that Resident #7 was repeatedly not compliant with the facility's smoking policy. On 11/17/20 at 11:55 AM, an interview was conducted with Employee Q, Unit Manager, who confirmed that the resident was a known smoker. A review of the resident's comprehensive care plans revealed that the resident was a noncompliant smoker. A review of the resident's annual assessment, dated 8/17/20, indicated that the resident did not use tobacco. A review of the resident's preceding quarterly assessment, dated 5/25/20, also indicated that the resident did not use tobacco. On 11/19/20 at 1:33 PM, an interview was conducted with the Minimum Data Set (MDS) Coordinator. She confirmed that the resident was a smoker who had repeatedly failed to follow the facility's smoking policy. The MDS Coordinator was asked to review the annual assessment, and she confirmed that the assessment had been coded inaccurately as it related to tobacco use. She explained that she was not sure why the MDS had not been coded to accurately reflect the resident's use of tobacco. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105632 If continuation sheet Page 7 of 29 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Harts Harbor 11565 Harts Rd Jacksonville, FL 32218 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff and resident interviews, the facility failed to implement the individualized care plan for one (Residents #135) of four residents sampled for activities, one (Resident #135) of two residents sampled for pressure ulcer/injury, and three (Residents #135, #44 and #45) of five residents sampled for Activities of Daily Living (ADLs) from a total sample of 56 residents. Failure to implement care plans places residents at risk for negative health care outcomes. The findings include: 1. During an interview with Resident #135 on 11/17/20 at 11:13 AM, he was observed sitting in a Geri-chair in his room. His heel protectors were not on his heels, the protector boot for his right foot was strapped to his right calf and was not under his heel. He was six feet from his call light, and it was not within his reach. It was clipped to the cord against the wall. Resident #135 was asked if he could squeeze the call light. He tried to take the call light in his hand but could not squeeze it hard or fast enough to get it to come on. The call light was checked and was working. When asked if he called out for help, he replied yes. There was no other means of alerting the staff to the resident's room in case of an emergency. The television was not on and no music was playing in his room. During an observation of Resident #135 on 11/18/2020 at 11:42 AM, he was lying in bed with his covers on. His eyes were closed and he appeared to be asleep. The resident's call light was not within reach. The television was not on. No music was playing in his room. His feet could be seen under the end of the blanket. His feet were bare. The heel protectors were off of both feet and were hanging over the edge of the bed. The resident's heels were against the mattress covered with a sheet. There was no device or support to relieve the pressure on them. The resident's entire right heel appeared to be dark black. (Photographic evidence obtained) During an observation of Resident #135 on 11/19/2020 at 2:45 PM in his room, he was seated in his Geri-chair. There was no music playing in his room. The television was on, but he was not watching it. A review of Resident #135's clinical record revealed he was admitted on [DATE] and readmitted on [DATE]. His diagnoses included cerebral infarction, respiratory failure with hypoxia, candida sepsis, sepsis due to Escherichia, cerebrovascular disease, anemia, essential hypertension, anxiety, schizo-affective disorder, hyperlipidemia, vascular dementia with behaviors, arthropathy , metabolic encephalophagy, syphilis, nicotine dependence, pressure ulcer - Stage II, pressure ulcer of unspecified site - unstageable, pressure-induced deep tissue damage of unspecified site - unspecified and protein-calorie malnutrition. A review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed the staff assessment of the resident's preferences included listening to music, snacks between meals, receiving a sponge bath, bed bath, shower. No other preferences were documented. A review of the current physician's orders revealed: Apply skin prep to right heel and continue using boot at all times. Every Monday and Thursday for pressure wound. Start 10/26/2020. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105632 If continuation sheet Page 8 of 29 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Harts Harbor 11565 Harts Rd Jacksonville, FL 32218 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Monitor resident used boot on feet all the time to avoid pressure. Start 10/14/2020. Level of Harm - Minimal harm or potential for actual harm Monitor both feet area both heel by pressure and notify immediately any change. Areas with necrotic tissue closed dry skin at the moment. Start 10/02/2020 (Photographic evidence obtained) Residents Affected - Few Review of the care plan for Resident #135 dated 11/16/2020 revealed the resident had focus areas including: a. ADL self-performance deficit. Interventions included: Encourage resident to use bell to call for assistance. b. Altered Cardiovascular status. Interventions included: Assess for chest pain as needed. Enforce the need to call for assistance if pain starts. c. Communication problem related to slurring due to stroke. Interventions included: Ensure/provide a safe environment: Call light in reach. d. At risk for falls related to gait/balance problems. Interventions included: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Frequent checks per physician order. e. The resident has actual/potential impairment to skin integrity related to fragile skin, blisters to back with itching, pressure areas to heels. Interventions included: Encourage good hydration in order to promote healthier skin. Pressure reduction boots as ordered. f. At risk for alteration in psychosocial well being related to fear of COVID-19, restriction on visitation and social isolation due to COVID-19. Interventions included: Provide in room activities of choice as indicated. g. Resident is dependent on staff for meeting emotional, intellectual, physical and social needs related to diagnoses. Interventions included: The resident needs bedside/in-room visits and activities if unable to attend out of room events. During an interview with Certified Nursing Assistant (CNA) N on 11/19/2020 at 2:45 PM, she stated Resident #135's call light was not within reach. She did not think he could use his call light. She did not state that he was on 15-minute checks. She left the room and did not address the resident's need for checks or rounding. During an interview with the Wound Care Nurse on 11/18/2020 at 9:28 AM, she stated the staff were to keep his heel boot on at all times, but sometimes they did not. She tried to remind them to do it. She was not certain about how long he had the wound. She thought it was first observed in October 2020. During an interview with Employee L, Activities Assistant, on 11/19/2020 at 3:20 PM, she confirmed she had only spent one to one time with Resident #135 on 11/02/2020. She confirmed that Resident #135 was not able to do most of the activities offered to other residents due to his physical and cognitive impairments. She stated she did not know of many activities that could be done for him. She confirmed that no music was being played in his room for him as per his preference. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105632 If continuation sheet Page 9 of 29 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Harts Harbor 11565 Harts Rd Jacksonville, FL 32218 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Resident #44 was interviewed on 11/16/2020 at 9:12 AM. The head of her bed was elevated 45 degrees. Her neck and head were bent over to her right side. Her right hand was in a hand splint. There was no hand bell on her tray table and her call light did not work. On 11/16/2020 at 4:15 PM, the call lights for Resident #44 and her roommate, Resident #45, were clipped on the cords against the wall behind the privacy curtain. Neither resident could reach their call light. (Photographic evidence obtained) The call light system had been repaired earlier in the day and was now functional. On 11/17/2020 at 9:15 AM, Resident #44 was lying in bed with a tray table over her bed. She had a spoon in her left hand and was eating a pudding supplement out of a plastic cup. She stated she wanted some water but could not reach it. The water cup was on her right hand side of the table. Her call light was not within reach. It was tied around the bed rail. When asked if she used her call light, she stated, Yes, I think I need that. The resident was handed her call light and she put it on. Resident #44 was interviewed on 11/18/20 at 2:45 PM. She was lying in bed with her covers on. The call light was clipped against the wall behind the privacy curtain. Resident #44 stated that her stomach was upset. She had not told the nurse yet. She wanted help with putting the straw in her unopened milk carton. This surveyor pushed the call light. CNA K responded to the call light. When shown the call light she stated, Oh yeah, she needs this. and took the call light and clipped it to the bed spread next to the resident's left hand. Licensed Practical Nurse (LPN) A was interviewed on 11/18/20 at 2:58 PM. She was asked to see this resident about her upset stomach. She was informed that the resident's call light was clipped against the wall and not within reach. She was asked if the resident could use her call light and she stated, Yes she can use it. She confirmed the CNAs needed to clip the call light near her left hand so she could use it. A review of Resident #44's clinical record revealed she was admitted on [DATE]. Her diagnoses included arthropathy, muscle weakness, difficulty walking, anorexia, type II diabetes with hyperglycemia, schizo-affective disorder, heart disease, gastroparesis, hyperlipidemia, anxiety, chronic kidney disease stage 1, anemia, hypertension, major depressive disorder, gastroesophageal reflux disorder, dementia without behavioral disturbance, protein-calorie malnutrition, glaucoma, ulcerative colitis with unspecified psychosis not due to substance or known physiological condition, dysthymic disorder, unspecified abdominal pain, unspecified pain and dry eye syndrome. A review of the Minimum Data Set (MDS) assessment dated [DATE], revealed the resident required limited assistance with most ADLs. She required extensive assistance to walk, for personal hygiene and for dressing. She had impairment on one side of her upper extremities (right). A review of the care plan dated 10/19/2018, revealed the resident had focus areas including: a. ADL self-performance deficit. Interventions included: Encourage resident to use bell to call for assistance. b. The resident is at risk for falls related to history of falls, confusion, gait/balance problems, incontinence, psychoactive drug us and vision/hearing problems. Interventions included: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Encourage to call for assistance. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105632 If continuation sheet Page 10 of 29 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Harts Harbor 11565 Harts Rd Jacksonville, FL 32218 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105632 If continuation sheet Page 11 of 29 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Harts Harbor 11565 Harts Rd Jacksonville, FL 32218 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to revise the care plan for one (Resident #65) of five residents reviewed for activities of daily living (ADLs) from a total sample of 56 residents, potentially contributing to his lack of grooming and personal hygiene. The findings include: A review of Resident #65's clinical record revealed he was admitted to the facility on [DATE] with a primary diagnosis of dementia with behavioral disturbances. Secondary medical diagnoses included anxiety and schizo-affective disorder. The resident's cognition was impaired, and he required extensive to total assistance with activities of daily living. An observation of Resident #65 was made on 11/15/2020 at 12:40 PM. He was lying in his bed. His food tray was sitting on the over-bed table with the plate and side items covered. His hair was greasy and disheveled, and his facial hair was unkempt. A second observation of Resident #65 was made on 11/16/2020 at 11:50 AM. He was attempting to feed himself while sitting in a Geri-chair, but was having difficulty using his utensils. His t-shirt and pants were visibly soiled with food. His hair was greasy and disheveled, and his facial hair was unkempt. A third observation of Resident #65 was made on 11/16/2020 at 2:53 PM. He was lying in bed and was wearing the same clothing he had on earlier in the day, which remained soiled with food. A fourth observation of Resident #65 was made on 11/18/2020 at 10:38 AM. He was lying in his bed. His hair remained greasy and disheveled, and his facial hair remained unkempt. His call light was clipped to the privacy curtain and was not within his reach. A review of the resident's comprehensive care plans revealed focus areas of activity of daily living self-care deficit. The care plan indicated the resident required limited assistance with personal hygiene and set-up help with bathing/showering. On 11/19/20 at 9:55 AM, an interview was conducted with the resident's assigned CNA, Employee N. She explained that the resident had experienced a decline since his hospitalization about two months ago, and that he had required total assistance with activities of daily living since that time. She explained that the resident had a history of refusing showers prior to his hospitalization, but that his behaviors had diminished greatly since being readmitted to the facility. She further explained that the resident's normal routine was to be clean shaven, and that she was not aware of any instances where he had refused to be shaved. On 11/19/20 at 10:25 AM, an interview was conducted with the resident's assigned nurse, Registered Nurse (RN) I. She explained that the resident required total assistance with activities of daily living and this was a change from his usual abilities. She stated she wasn't sure how long the decline had been occurring, and wasn't aware of any instances where the resident had refused care recently. A review of the resident's care flow records indicated that from 10/20/2020 through 11/18/2020, the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105632 If continuation sheet Page 12 of 29 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Harts Harbor 11565 Harts Rd Jacksonville, FL 32218 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident received two showers. The showers were documented on 10/31/2020 and 11/9/2020. There were no documented refusals. The records also reflected that the resident required total assistance with hygiene and dressing. No refusals were documented. On 11/19/2020 at 1:24 PM, an interview was conducted with the Minimum Data Set (MDS) Coordinator. She confirmed that Resident #65 had experienced a change in condition and his self-care abilities had declined since hospitalization. She confirmed that she believed the resident required extensive to total assistance with activities of daily living. She was asked to review the resident's care plans and confirmed that the resident's care requirements for personal hygiene, dressing, and feeding did not accurately reflect the resident's current care needs. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105632 If continuation sheet Page 13 of 29 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Harts Harbor 11565 Harts Rd Jacksonville, FL 32218 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to provide assistance with dressing and personal hygiene for one (Resident #65) of five residents reviewed for activities of daily living (ADLs) from a total sample of 56 residents. Residents Affected - Few The findings include: A review of Resident #65's clinical record revealed he was admitted to the facility on [DATE] with a primary diagnosis of dementia with behavioral disturbances. Secondary medical diagnoses included anxiety and schizo-affective disorder. The resident's cognition was impaired, and he required extensive to total assistance with activities of daily living. An observation of Resident #65 was made on 11/15/2020 at 12:40 PM. He was lying in his bed. His food tray was sitting on the over-bed table with the plate and side items covered. His hair was greasy and disheveled, and his facial hair was unkempt. A second observation of Resident #65 was made on 11/16/2020 at 11:50 AM. He was attempting to feed himself while sitting in a Geri-chair, but was having difficulty using his utensils. His t-shirt and pants were visibly soiled with food. His hair was greasy and disheveled, and his facial hair was unkempt. A third observation of Resident #65 was made on 11/16/2020 at 2:53 PM. He was lying in bed and was wearing the same clothing he had on earlier in the day, which remained soiled with food. A fourth observation of Resident #65 was made on 11/18/2020 at 10:38 AM. He was lying in his bed. His hair remained greasy and disheveled, and his facial hair remained unkempt. His call light was clipped to the privacy curtain and was not within his reach. On 11/19/20 at 9:55 AM, an interview was conducted with the resident's assigned CNA, Employee N. She explained that the resident had experienced a decline since his hospitalization about two months ago, and that he had required total assistance with activities of daily living since that time. She explained that the resident had a history of refusing showers prior to his hospitalization, but that his behaviors had diminished greatly since being readmitted to the facility. She further explained that the resident's normal routine was to be clean shaven, and that she was not aware of any instances where he had refused to be shaved. On 11/19/20 at 10:25 AM, an interview was conducted with the resident's assigned nurse, Registered Nurse (RN) I. She explained that the resident required total assistance with activities of daily living and this was a change from his usual abilities. She stated she wasn't sure how long the decline had been occurring, and wasn't aware of any instances where the resident had refused care recently. A review of the resident's care flow records indicated that from 10/20/2020 through 11/18/2020, the resident received two showers. The showers were documented on 10/31/2020 and 11/9/2020. There were no documented refusals. The records also reflected that the resident required total assistance with hygiene and dressing. No refusals were documented. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105632 If continuation sheet Page 14 of 29 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Harts Harbor 11565 Harts Rd Jacksonville, FL 32218 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review and staff interview, the facility failed to provide a program of activities that met the interests of one (Resident #135) of four residents sampled for activities, from a total of 56 sampled residents. Failing to promote and invite residents to activities of personal interest may result in a decline of quality of life, placing the resident at risk of not reaching his/her highest level of psychosocial well-being. Residents Affected - Few The findings include: During an interview with Resident #135 on 11/17/20 at 11:13 AM, he was observed sitting in a Geri-chair in his room. He stated he was okay. The television was not on and no music was playing in his room. During an observation of Resident #135 on 11/18/2020 at 11:42 AM, he was lying in bed under his covers. The television was not on and no music was playing in his room. During an observation of Resident #135 on 11/19/2020 at 2:45 PM in his room, he was seated in his Geri-chair. There was no music playing. The television was on, but the resident was not watching it. A review of Resident #135's clinical record revealed he was admitted on [DATE] and readmitted on [DATE]. His diagnoses included cerebral infarction, respiratory failure with hypoxia, candida sepsis, sepsis due to Escherichia, cerebrovascular disease, anemia, essential hypertension, anxiety, schizo-affective disorder, hyperlipidemia, vascular dementia with behaviors, arthropathy, metabolic encephalophagy, syphilis, nicotine dependence, pressure ulcer - Stage II, pressure ulcer of unspecified site - unstageable, pressure-induced deep tissue damage of unspecified site and unspecified protein-calorie malnutrition. A review of the annual Minimum Data Set (MDS) assessment, dated 05/07/2020, revealed that staff assessed the resident's preferences as listening to music, snacks between meals, receiving a sponge bath, bed bath, a shower. No other preferences were documented. (Electronic copy obtained) A review of the care plan for Resident #135, dated 11/16/2020, revealed the resident had focus areas including: a. At risk for alteration in psychosocial well being related to fear of COVID-19, restriction on visitation and social isolation due to COVID-19. Interventions included: Provide in room activities of choice as indicated. b. Resident is dependent on staff for meeting emotional, intellectual, physical and social needs related to diagnoses. Interventions included: The resident needs bedside/in-room visits and activities if unable to attend out of room events. (Photographic evidence obtained) A review of the November 2020 Activities Log for Resident #135 revealed the following entries: 11/02/2020. In room visit. Resident got his nails 11/05/2020 In-room visit. cut today. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105632 If continuation sheet Page 15 of 29 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Harts Harbor 11565 Harts Rd Jacksonville, FL 32218 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 11/08/2020 In-room visit. Resident was looking at his TV in his room. Level of Harm - Minimal harm or potential for actual harm 11/14/2020 In-room visit. Resident was asleep. 11/18/2020 In-room visit. Resident was taking a shower. Residents Affected - Few (Photographic evidence obtained) During an interview with Employee L, Activities Assistant, on 11/19/2020 at 3:20 PM, she confirmed she had only spent one to one time with Resident #135 on 11/02/2020. She confirmed that no music was being played in his room for him as per his preference. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105632 If continuation sheet Page 16 of 29 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Harts Harbor 11565 Harts Rd Jacksonville, FL 32218 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interview and facility policy and procedure review, the facility failed to prevent the development of a deep tissue wound for one (Resident #135) of two residents sampled for pressure ulcers. The facility failed to consistently follow the physician's treatment orders to monitor the resident's heels and apply pressure reducing boots to the resident's lower extremities on all shifts, all the time. Failure to apply prescribed pressure reducing devices/methods to prevent the development/worsening of pressure ulcers, places the resident at risk for potential wound development/worsening of current wounds and possible infection of wounds. Residents Affected - Few The findings include: During an interview with Resident #135 on 11/17/2020 at 11:13 AM, he was sitting in a Geri-chair in his room. His heel protectors were not on his heels, the protector boot for his right foot was strapped to his right calf and was not under his heel. During an observation of Resident #135 on 11/18/2020 at 11:42 AM, he was lying in bed with his covers on. His bare feet could be seen under the end of the blanket. The heel protectors were off of both feet and were hanging over the edge of the bed. The resident's heels were against the mattress and covered with a sheet. There was no device or support to relieve the pressure on them. The resident's entire right heel appeared to be dark black. (Photographic evidence obtained) Resident #135 was admitted on [DATE] and readmitted on [DATE]. His diagnoses included: cerebral infarction, respiratory failure with hypoxia, candida sepsis, sepsis due to Escherichia, cerebrovascular disease, anemia, essential hypertension, anxiety, schizo-affective disorder, hyperlipidemia, vascular dementia with behaviors, arthropathy , metabolic encephalophagy, syphilis, nicotine dependence, pressure ulcer - Stage II, pressure ulcer of unspecified site - unstageable, pressure-induced deep tissue damage of unspecified site and unspecified protein-calorie malnutrition. A review of the quarterly Minimum Data Set (MDS) assessment, dated 08/03/2020, revealed Resident #135 was at risk for pressure ulcer development. He had no pressure ulcers/injuries and no unstageable deep tissue injuries. The resident received application of ointments/medications other than to feet. A review of the quarterly MDS assessment, dated 11/02/2020, revealed Resident #135 was assessed as not being at risk of pressure ulcer development and not having any unhealed pressure ulcers. He had no unstageable deep tissue injuries. He had a pressure reducing device for his bed. The resident received application of ointments/medications other than to feet. A review of the physician's orders revealed: Apply Skin prep to right heel and continue using boot at all times. Every Monday and Thursday for pressure wound. Start 10/26/2020. Monitor resident used boot on feet all the time to avoid pressure. Start 10/14/2020. Monitor both feet area both heel by pressure and notify immediately any change. Areas with necrotic tissue closed dry skin at the moment. Start 10/02/2020. (Photographic evidence obtained) A review of the care plan for Resident #135, dated 11/16/2020, revealed the resident had focus (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105632 If continuation sheet Page 17 of 29 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Harts Harbor 11565 Harts Rd Jacksonville, FL 32218 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 areas including: Level of Harm - Minimal harm or potential for actual harm The resident has actual/potential impairment to skin integrity related to fragile skin, blisters to back with itching, pressure areas to heels. Interventions included: Encourage good hydration in order to promote healthier skin. Pressure reduction boots as ordered. Identify/document potential causative factors and eliminate/resolve where possible. Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection, maceration etc. to physician. Pad bed rails, wheelchair arms or any other source of potential injury if possible. Residents Affected - Few A review of the facility's Weekly Skin Integrity Review, dated 10/01/2020, revealed that a necrotic intact area to the right heel was observed by the nurse. The skin was intact. Notes read: treatment in place skin prep to right heel. A review of the change of condition Situation, Background, Assessment, Recommendation (SBAR) form, dated 10/01/2020, revealed the change of condition noted as necrotic heel on right foot. The condition had stayed the same. It was unknown if the condition had occurred before. There were no changes to the resident's functional status, behavior evaluation, respiratory evaluation, cardiovascular evaluation, abdominal/gastro-intestinal evaluation, urinary evaluation or neurological evaluation. Altered level of consciousness was noted and skin evaluation noted Other. No pain noted. Change in medication noted. A review of the contracted Wound Care physician progress note, dated 10/19/2020, revealed: Patient presents with a wound on his right heel. A thorough wound care assessment and evaluation was preformed today. He has an unstageable deep tissue injury (DTI) of the right heel of at least 12 days duration. There is no exudate. There is no indication of pain associated with this condition. Focused wound exam: Unstageable DTI of the right heel. Etiology: Pressure. Wound size: length: 5.7 x width 7.5 x depth was not measurable. Surface area 42.75 cm (centimeters) squared. A review of the facility's Weekly Skin Integrity Review form, dated 10/23/2020, revealed the resident had a right heel unstageable pressure wound measuring 5.7cm x 7.5cm x depth not measurable. The wound bed had eschar (dead tissue). The color of the skin was black. The peri-wound area was assessed as hardness/induration. Notes read: Resident needs continue using boot all the time to avoid pressure and will be monitored by change, area unstageable DTI (deep tissue injury) with intact skin. A review of the facility's Weekly Skin Integrity Review form, dated 10/30/2020, revealed the skin was intact. Notes read: Previous noted area to right heel. The site was not documented. The resident had no other wounds. A review of the facility's Weekly Skin Integrity Review form, dated 11/19/2020, revealed the resident had a right heel unstageable pressure wound measuring 2.9 cm x 3.1 cm x depth was not measurable. The wound bed had eschar. The color of the skin was black. The peri-wound area was assessed as having redness and temperature difference. Notes read: Resident needs continue using boot all the time to avoid pressure and will be monitored by change. During an interview with the Wound Care Nurse (WCN) on 11/18/2020 at 9:28 AM, she stated Resident #135 did not have an open wound on his heel. It was a deep tissue injury and was not open. She only applied skin prep to the area. It was not bandaged. The staff were to keep his heel boot on at all times, but sometimes they did not. She tried to remind them to do it. She was not certain about how long he had the wound. She thought it was first observed in October 2020. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105632 If continuation sheet Page 18 of 29 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Harts Harbor 11565 Harts Rd Jacksonville, FL 32218 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the facility's policy and procedure entitled Pressure Injury Record, WC-130 (dated 11/30/2014, effective 11/30/2014 and revised 04/01/2017) revealed: Document the presence of skin impairment/new skin impairment related to pressure when first observed. Residents will have a pressure injury record completed for each skin impairment that is related to pressure. A review of the facility's policy and procedure entitled Clinical Guideline Skin & Wound, WC-100 (effective 04/01/2017) revealed: Provide a system for identifying skin at risk, implementing individual interventions including evaluation and monitoring as indicated to promote skin health, healing and decrease worsening of/prevention of pressure injury. On admission/re-admission the resident's skin will be evaluated for baseline skin condition and documented in the medical record. Braden Risk Evaluation to be completed on with a significant change in condition. Licensed Nurse to complete skin observation and document in medical record. CNA to complete skin observations and report to Licensed Nurse. Licensed Nurse to document presence of skin impairment/new skin impairment when observed and weekly until resolved. Licensed Nurse to report changes to skin integrity to the physician and resident/responsible party and document in medical record. Develop individualized goals and interventions and document on the care plan and the CNA [NAME]. Monitor resident's response to treatment and modify treatment as indicated. Evaluate the effectiveness of interventions, and progress towards goals during the care and management meeting and as needed. Patterns and trends of newly developed and or worsening skin conditions will be reviewed by the Quality Assurance and Performance Improvement (QAPI) team. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105632 If continuation sheet Page 19 of 29 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Harts Harbor 11565 Harts Rd Jacksonville, FL 32218 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and staff interviews, the facility failed to provide adequate supervision to ensure the resident environment remained as free of accident hazards as possible for one (Resident #7) of one sampled resident who smoked, from a total sample of 56 residents. The findings include: A review of the clinical record for Resident #7, revealed she was admitted to the facility on [DATE] with a primary medical diagnosis of seizures. Her secondary medical diagnoses included bipolar disorder and schizo-affective disorder. Her cognition was intact and she was able to make her own medical decisions. The resident required extensive assistance with most activities of daily living. On 11/17/20 at 11:11 AM, Resident #7 was observed exiting the main dining room through a door leading to the courtyard. The resident removed a cigarette from a pack being kept on her person. She then retrieved a lighter from her coat pocket, lit the cigarette, and proceeded to smoke. The facility's assistant administrator was notified. She assisted the resident back into the facility and explained that Resident #7 was repeatedly not compliant with the facility's smoking policy. On 11/17/20 at 11:30 AM, an observation was made of the courtyard area. There were no ashtrays, fire extingushers, smoking aprons, or fire blankets observed in the area. On 11/17/20 at 11:55 AM, an interview was conducted with the Unit Manager who confirmed that the resident was a known smoker. A review of the resident's comprehensive care plans revealed that the resident was a noncompliant smoker. She stated, I guess she got caught outside smoking again. I think she did that the last time you were here. I think we need to put her on safety checks. A review of the resident's most recent smoking evaluation revealed the resident had short- and long-term memory impairment and was determined to be an unsafe smoker. The assessment indicated that constant supervision was required while smoking. A review of the resident's physician's orders revealed orders for Seroquel (antipsychotic medication), gabapentin (anticonvulsant), Xtampza (narcotic pain medication), fluoxetine, clonazepam (Benzodiazepine), and amitriptyline (antidepressant). Potential side effects of these medications included drowsiness. A review of the resident's comprehensive care plans revealed a focused area for smoking. The care plan indicated the resident would not smoke without supervision. The facility's policy for smoking, titled Smoking - Supervised, indicated that residents would be supervised during smoking and that smoking materials would be retained and stored by the nursing staff for all residents having been granted smoking privileges. On 11/18/20 at 9:44 AM, an interview was conducted with the Director of Nursing. She was asked what actions the facility had taken to ensure the safety of Resident #7 and other residents. She confirmed that the resident had not been placed on continuous supervision as the most recent smoking evaluation indicated, but she thought it was a good idea. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105632 If continuation sheet Page 20 of 29 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Harts Harbor 11565 Harts Rd Jacksonville, FL 32218 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105632 If continuation sheet Page 21 of 29 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Harts Harbor 11565 Harts Rd Jacksonville, FL 32218 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to appropriately administer and maintain oxygen for one (Resident #98) of one resident reviewed for oxygen use. Residents Affected - Few The findings include: A review of the clinical record for Resident #98 revealed she was admitted to the facility on [DATE]. Her primary medical diagnosis was chronic obstructive pulmonary disorder with a secondary diagnosis of schizophrenia. Her cognition was impaired and she required extensive assistance with activities of daily living. On 11/15/20 at 10:30 AM, Resident # 98 was observed sitting in her wheelchair holding a nasal cannula in her hand which was not connected to an oxygen source. The assigned nurse brought an oxygen concentrator into the room which did not function properly. The nurse brought another concentrator to the room which also did not function properly. A third concentrator was brought to the room which was functioning. The resident was then reconnected to an oxygen source. The resident's oxygen flow rate was set at 5 liters per minute. On 11/16/20 at 11:22 AM, Resident #98 was observed lying in bed with a nasal cannula in place. The oxygen tubing was not dated and there was no humidification connected to the concentrator. The oxygen flow rate was set at 5 liters per minute. On 11/18/20 at 10:41 AM, Resident #98 was observed lying in her bed with a nasal cannula in place. The oxygen concentrator was set at 4 liters per minute. There was no humidification connected to the concentrator. On 11/18/20 at 4:02 PM, an interview was conducted with the Regional Nurse Consultant regarding the facility's use of humidification for oxygen. She explained that humidification was used if the oxygen flow rate was 4 liters per minute or higher, or if the resident preferred to use it. A review of the resident's physician's orders revealed an order for oxygen: 1. Oxygen at 3 liters per minute as needed for shortness of breath. A review of the resident's medical provider notes, dated 10/7, 11/6 and 11/13, indicated oxygen at 3 liters continuously. A review of the resident's comprehensive care plans revealed a focused area for emphysema and ineffective gas exchange. The resident's care plan for emphysema indicated an oxygen setting of 2 liters continuously. The resident's care plan for ineffective gas exchange indicated the use of oxygen without a liter setting. On 11/19/20 at 10:20 AM, an interview was conducted with the resident's primary nurse. She observed the resident's oxygen settings and stated, It looks like it's set to 4.5 to 5. The nurse was asked to review the resident's oxygen orders. She confirmed the order for 3 liters of oxygen as needed. She explained that she would notify the physician and obtain a new order. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105632 If continuation sheet Page 22 of 29 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Harts Harbor 11565 Harts Rd Jacksonville, FL 32218 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105632 If continuation sheet Page 23 of 29 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Harts Harbor 11565 Harts Rd Jacksonville, FL 32218 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on food service observations, dietary staff interview and facility policy and procedure review, the facility failed to maintain sanitary conditions in the main kitchen and the nutrition rooms by following proper sanitation and food handling practices to prevent the outbreak of foodborne illness. Unsafe food handling practices represent a potential source of pathogen exposure. Failure to maintain sanitary food preparation and storage areas can potentially put the residents at risk of foodborne illness. The findings include: During the initial tour of the kitchen on 11/15/2020 at 11:14 AM, the cove molding was broken next to the hand sink in the kitchen. Stainless steel baking pans were wet nesting next to the sink on a shelf. A fly had landed on a plastic bag containing a dinner roll. (Photographic evidence obtained) The fly was observed landing on prep tables and other high-touch surfaces in the kitchen during the tour. A tray of prepared sandwiches was date marked 11/09/2020 with a use-by date of 11/12/2020 in the reach in cooler. (Photographic evidence obtained) A service cart near the tray line was observed with prepared bowls of food on the top. The cart was wet with food debris and an empty butter cup on the lower shelf. (Photographic evidence obtained) The storage rack for the insulated plate domes and bases was not clean and had water and food debris on it. (Photographic evidence obtained) The insulated plate domes and bases were still wet on one rack as the staff were preparing the tray line for meal service. (Photographic evidence obtained) Plastic lids were observed under the storage rack next to the ice machine. (Photographic evidence obtained) The ice machine had a black biological growth on the outside of the chute. (Photographic evidence obtained) The gaskets to the walk-in cooler were covered with a black biological substance. The side of the walk in cooler around the latch was covered in a black biological film. (Photographic evidence obtained) Dust and debris were observed on fan cages in the walk-in cooler and walk-in freezer. (Photographic evidence obtained) The outside of the walk-in freezer had a dark black build up of grime around the latch on the door. (Photographic evidence obtained) During a second tour of the kitchen on 11/16/2020 at 10:00 AM, the air grate above the ice machine was covered with stuck-on dust and debris. (Photographic evidence obtained) The deep fat fryer had old grease that had run down the sides stuck to the outside of the bottom and had dripped onto the floor. (Photographic evidence obtained) Employee P was observed to bring a stack of insulated plate domes and bases out of the dish room and stack them on a lower shelf under the coffee maker. The domes and bases were still wet, and he did not separate them to air dry. (Photographic evidence obtained) The shelves in the walk-in cooler were observed to have a black and yellow biological growth on them. (Photographic evidence obtained) A fly was observed in the kitchen and a gnat in the dish room. Stainless steel utensils were observed to be in a dishwashing basket wet and not air dried. Employee O was wrapping them in napkins. She banged the utensils on the side of the basket to get the water off of them prior to wrapping them. She stated at 11:20 AM that the utensils were wet, and they did not have any other utensils to use that had been air dried. The ice machine still had a black biological growth on the outside of the chute. Dust and debris was observed on the fan cages in the walk-in cooler and walk-in freezer. Food waste was observed on the insulated plate domes and bases on the tray line being used for meal service. (Photographic evidence obtained) The stack of insulated plate domes and bases on the tray line being used for meal service were wet nested. Water could be seen dripping off the insulated domes when Employee Q covered the plated food for meal service to the residents' rooms. The gaskets on the walk-in cooler were still covered with black biological growth. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105632 If continuation sheet Page 24 of 29 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Harts Harbor 11565 Harts Rd Jacksonville, FL 32218 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm The nutrition rooms on each unit were observed (total of three) on 11/19/2020 beginning at 1:10 PM. The ice machines on each unit were not clean. A black biological growth was observed on each of the three machines. (Photographic evidence obtained) The ice machine on the North Unit had rust on the inside of the machine. The rust had dripped down into the ice making the ice appear orange. (Photographic evidence obtained) Residents Affected - Many During the final tour of the kitchen on 11/19/2020 at 2:35 PM, the facility's Dietician and Food Service Manager toured with this surveyor. The findings were shown to the staff and the Food Service Manager acknowledged the lack of sanitation throughout the kitchen, the food being past the use-by date, the ice machines not being clean and the wet nesting of equipment. A review of the facility's policy and procedure entitled Environment, HCSG Policy 028 (last revised 09/2017) revealed: All food preparation areas, food service areas and dining areas will be maintained in a clean and sanitary condition. 1. The Dining Services Director will ensure that the kitchen is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting and ventilation. 3. All food contact surfaces will be cleaned and sanitized after each use. (Copy obtained) A review of the facility's policy and procedure entitled Equipment, HCSG Policy 027 (last revised on 9/2017) revealed: All food service equipment will be clean, sanitary and in proper working order. 1. All equipment will be routinely cleaned and maintained in accordance with manufacturer's directions and training materials. 2. All staff members will be properly trained in the cleaning and maintenance of all equipment. 3. All food contact equipment will be clean and sanitized after every use. 4. All non-food contact equipment will be clean and free of debris. 5. The Dining Services Director will submit requests for maintenance or repair to the Administrator and/or Maintenance Director as needed. (Copy obtained) A review of the facility's policy and procedure entitled Ice, HCSG Policy 021 (last revised on 9/2017) revealed: Ice will be prepared and distributed in a safe and sanitary manner. 2. The Dining Services Director will coordinate with the Maintenance Director to ensure that the ice machine will be disconnected, cleaned and sanitized quarterly and as needed. (Copy obtained) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105632 If continuation sheet Page 25 of 29 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Harts Harbor 11565 Harts Rd Jacksonville, FL 32218 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observations and interviews, the facility failed to ensure the proper use of personal protective equipment (PPE - masks) (Certified Nursing Assistant (CNA) N), and it failed to ensure handwashing consistent with accepted standards of practice to reduce the spread of infections and prevent cross-contamination (CNA G). Residents Affected - Few The findings include: 1. During an interview with the Infection Control Preventionist (ICP) on 11/15/20 at 1:05 PM, she stated the expectation was that staff wear a surgical mask. During an observation of the North Unit on 11/18/20 at 3:55 PM, Certified Nursing Assistant (CNA) N was observed wearing her surgical face mask around her neck just as she was about to enter Resident #47's room. During an interview on 11/18/20 at 3:55 PM, CNA N stated, It's not the correct way to wear the mask. It's my fault. I couldn't breathe so I took it off. I know I should put it on. She then put the mask on covering her nose. 2. During an observation of resident care on the North Unit on 11/18/20 at 10:35 AM, CNA G was observed in Resident #3's room assisting her with her personal items. CNA G did not perform hand hygiene after assisting Resident #3. CNA G was observed touching the resident's high touch areas including the bedside table and clothes. She was observed leaving the room without performing hand hygiene. During an interview with CNA G on 11/18/20 at 10:50 AM, she stated, I was just helping the resident get dressed. She is new to the facility. When questioned about handwashing, CNA G then performed hand hygiene by using hand sanitizer. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105632 If continuation sheet Page 26 of 29 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Harts Harbor 11565 Harts Rd Jacksonville, FL 32218 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observations, staff and resident interviews and facility policy and procedure review, the facility failed to ensure essential equipment was in good repair and safe operating condition, evidenced by insulated plate domes and bases in the kitchen which were chipped and cracked, the ice machine in one (North Unit) of three nutrition rooms which was rusted inside, a bed controller in one (Resident #503) of 31 beds observed was nonfunctional, and two of three washing machines in the facility were not in safe operating condition. This had the potential to affect more than a limited number of residents. Residents Affected - Many The findings include: 1. During the initial tour of the kitchen on 11/15/2020 at 11:14 AM, several insulated plate domes and bases were observed to be in disrepair with chips and cracks in the plastic. They were stacked in a pile on the tray line as the staff prepared to plate the lunch meal for service to the residents' rooms. The staff used the insulated domes and bases even though they were cracked and chipped. During a second tour of the kitchen on 11/16/2020 at 11:30 AM, the insulated plate domes and bases that were observed on 11/15/2020 were observed being used by the dietary staff to cover the plated food during the lunch meal service. During the final tour of the kitchen on 11/19/2020 at 2:35 PM, the soiled meal trays were stacked on rolling carts outside the dish room waiting to be washed. Several insulated domes and bases were observed on the carts which were cracked and chipped. During an interview with the Food Service Manager on 11/16/2020 at 11:25 AM, he stated he bought the insulated plate covers every couple of months. He ordered thirty new ones at a time and got rid of the old cracked ones. He told his staff to bring the cracked ones to him when they saw they were cracked, but that usually did not happen. 2. The nutrition rooms on each unit were observed (three in total) on 11/19/2020 at 1:10 PM. The ice machine on the North Unit had rust on the inside of the machine. The rust had dripped down into the ice making the ice appear orange. (Photographic evidence obtained) During the final tour of the kitchen on 11/19/2020 at 2:35 PM, the facility Dietician and the Food Service Manager toured with this surveyor. The Food Service Manager was shown the insulated domes and bases that were in disrepair and was informed of the ice machine on the North unit being rusted. He acknowledged the equipment being in disrepair. A review of the facility's policy and procedure entitled Equipment, HCSG Policy 027 (last revised on 9/2017) revealed: All food service equipment will be clean, sanitary and in proper working order. 1. All equipment will be routinely cleaned and maintained in accordance with manufacturer's directions and training materials. 2. All staff members will be properly trained in the cleaning and maintenance of all equipment. 3. All food contact equipment will be clean and sanitized after every use. 4. All non-food contact equipment will be clean and free of debris. 5. The Dining Services Director will submit requests for maintenance or repair to the Administrator and/or Maintenance Director as needed (Copy obtained). Review of the facility policy and procedure entitled Ice, HCSG Policy 021 last revised on 9/2017 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105632 If continuation sheet Page 27 of 29 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Harts Harbor 11565 Harts Rd Jacksonville, FL 32218 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many revealed it read: Ice will be prepared and distributed in a safe and sanitary manner. 2. The Dining Services Director will coordinate with the Maintenance Director to ensure that the ice machine will be disconnected, cleaned and sanitized quarterly and as needed. (Copy obtained) 3. An observation in Resident #503's room on 11/16/20 at 10:20 a.m., found Resident #503's bed was not reclining. The bed control was not in working condition. On 11/16/20 at 10:25 a.m., Resident #503 stated she could not recline her bed because her bed control was broken. She also stated, I told nursing staff last week when I arrived, and the nurse said someone would come back to fix it. No one came to fix it. Its uncomfortable for me. During an interview with Employee B, Maintenance Staff, on 11/19/20 at 1:00 p.m., he confirmed the bed control needed repair in the room occupied by Resident #503. He stated, It should be working now. I found a bed to replace it yesterday. 4. An observation of the laundry room on 11/19/20 at 8:30 a.m., found two out of three washing machines were not in working condition. The facility was down to one washer to process laundry and linens for 155 residents. During an interview with the Maintenance Supervisor on 11/19/20 at 8:40 a.m., he confirmed the two washing machines needed replacement. He stated the facility had been operating with only one washing machine for all residents for about three to four months now. During an interview with the Administrator on 11/19/20 at 10:00 a.m., he confirmed the two washing machines needed replacement. The Administrator stated, The facility is operating with only one washing machine for all residents. We got approved for two new washing machines on 11/4/20. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105632 If continuation sheet Page 28 of 29 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Harts Harbor 11565 Harts Rd Jacksonville, FL 32218 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain a functioning call system on the facility's South unit. Residents Affected - Some The findings include: On 11/15/20 at 11:30 AM, observations of residents on the South unit were conducted. Residents were noted with hand bells and were using them to call for staff assistance. On 11/16/20 at 10:00 AM, two residents were observed in South room [ROOM NUMBER]. They had been transferred from the North Unit the evening prior. A staff member was observed removing the wrapping from two hand bells and then provided the bells to the two residents. On 11/16/20 at 10:25 AM, an interview was conducted with the Assistant Administrator regarding the facility's call light system on the South unit. She explained that the system had gone down on the previous Friday and that the repair company had been notified. However, the repair company was unable to respond until 11/16/20. She explained that the nursing team had passed out hand bells to the residents but was not sure whether the residents were assessed to be sure they could use the bells. On 11/16/20 at 11:00 AM, an interview was conducted with the Director of Nursing (DON) regarding the facility's call bell system on the South unit. She explained that the issue was brought to her attention on the previous Friday and that she was under the impression that the situation had been handled by the maintenance director. The DON further explained that hand bells had been passed out to each resident on the unit, but that she wasn't sure if each resident had been assessed to ensure they could use the bell. She stated safety checks were initiated on the unit and were to be conducted every 15 minutes. The DON stated she was going to immediately have each resident assessed and interviewed to ensure no harm had come to any resident. On 11/16/20 at 2:00 PM, the DON produced documentation of 15 minute safety check forms which were initialed by a staff member. The DON was asked whether the two residents in room [ROOM NUMBER] had been provided with hand bells at the time they were transferred to the South unit. She stated she wasn't sure but she thought so, as someone had come and taken a bell from her office. On 11/16/20 at 4:39 PM, an interview was conducted with the Administrator and Maintenance Director. The Administrator explained that the repair company had just completed their work and that the call system was now functional. The Maintenance Director explained that the system had stopped working on 11/13/20, and that he notified the Administrator and DON of the same during the morning meeting. The Administrator was not sure whether the residents in room [ROOM NUMBER] had been given a hand bell at the time of their transfer, and he was not sure whether any residents had been assessed to ensure they could use the bells. A review of the facility's policy titled Call Bell System - Inoperable indicated that residents must have a system to notify staff at all times. The policy also indicated that hand bells or tap bells would be placed within reach of any resident affected by an inoperable call bell. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105632 If continuation sheet Page 29 of 29